Spoken vs written conversations:

Karen Cosby kcosby40 at GMAIL.COM
Fri Aug 16 13:18:55 UTC 2013

We should perhaps distinguish between best modes of communication based on
setting.  A pathology report may guide treatment over time and between
multiple specialities.  A well-designed, methodical, and thorough report is
desirable no doubt.  In contrast, an XR or CT for a patient in the ED may
influence immediate decisions and actions. Not all written reports are
reliable.  I pull down a drop menu to select purpose of exam.  My
Radiologist may use a voice dictation which may or may not be accurate. The
ability to question and confirm (Did you understand my concern? Do I
understand what you think? Are you sure you considered a specific
diagnosis?  Did you notice an area of concern I have?) is very helpful in
the moment.  My concern is when someone accepts a written report without
considering that a conversation could clarify misunderstanding or give a
chance to interact with a specialist who might better inform them.  Written
reports shouldn't replace conversations; conversations shouldn't stand

On Thu, Aug 15, 2013 at 3:52 PM, Lorri Zipperer <Lorri at zpm1.com> wrote:

> Fw w/new subject heading by moderator -- ****
> ** **
> *From:* Swerlick, Robert A [mailto:rswerli at emory.edu]
> *Sent:* Thursday, August 15, 2013 2:07 PM
> *To:* Society to Improve Diagnosis in Medicine; Karen Cosby
> *Subject:* RE: [IMPROVEDX] Errors in Oncology Pathologies****
> ** **
> I am not such an enthusiast when it comes to spoken vs written
> communications. In my experience what is spoken may be very different from
> what is heard and what is initially heard may be very different from what
> is remembered. Spoken communications have a relatively short half lives.
> That is the reason we generate written reports. Conversations are useful
> but the information conveyed may be inconsistent and non-enduring. They are
> certainly better than no communication whatsoever. ****
>  ****
> Bob Swerlick****
>  ****
> *From:* Karen Cosby [mailto:kcosby40 at gmail.com <kcosby40 at gmail.com>]
> *Sent:* Thursday, August 15, 2013 3:08 PM
> *Subject:* Re: [IMPROVEDX] Errors in Oncology Pathologies****
>  ****
> I agree with Dr. Gordon (and of course I am a practicing emergency
> physician).  Listening to this dialogue, I am surprised how awkward the
> exchange of clinically relevant information is when it is indirect, say via
> a search of the medical record or review of an order. Whenever possible I
> find a first hand conversation is the most effective way to yield useful
> information.  Both sides can ask questions, discuss nuances of the case,
> and question each other's findings.  Back when I was a student and attended
> "tumor board" I was amazed at how often pathologists and radiologists
> altered their opinion when provided background and context.  Many of the
> significant errors I've seen reported have to do with generalists
> mis-interpeting written reports or specialists not fully understanding
> clinical context.  Why is our practice designed to make a conversation the
> exception rather than the rule? ****
>  ****
> On Wed, Aug 14, 2013 at 3:07 PM, David Gordon, M.D. <
> davidc.gordon at duke.edu> wrote:****
> I wanted to share some other thoughts in hope of contributing to this very
> useful discussion. This comes from the perspective of an emergency
> physician practicing at an academic center with many radiology
> interpretations coming preliminarily from residents - not board certified
> attendings, so not all of this may be generalizable to practice at-large.
>  (I also can't speak to how this applies to pathology as I do my best to
> avoid these services in my line of profession).
> 1) In terms of measuring overall diagnostic accuracy in radiology, I
> wanted to echo a point made by Stefanie Lee in a separate thread that there
> can be value in engaging the radiologist prior to the study being performed
> to make sure the correct study has been ordered in the first place (e.g., a
> chest CT to evaluate for pulmonary embolism will be protocolized
> differently for one to exclude aortic dissection).  I have a general sense
> for the protocols out there, but also know there are times where I need to
> confer with my radiology colleagues.   So in asking overall  whether
> clinical information helps or hinders radiologic diagnosis, not only
> correct image interpretation but also correct study acquisition should be
> considered.
> 2) I take a variable approach in terms how much information I provide to
> the radiologist and more specifically whether I just provide "clinical
> data" or additionally provide a preliminary "clinical impression."  This is
> based on whether the patient is still broadly undifferentiated or whether
> there is a specific disease process I am worried about. I always provide
> clinical data (e.g., location of pain, presence of fever, leukocytosis,...)
> and if the patient is undifferentiated  that is all I provide. If, however,
> there is a diagnosis jumping out at me that I am specifically looking out
> for, I will also include this preliminary impression  in the form of
> "concern for..."  Perhaps never providing a clinical impression will prove
> to be best, but I wanted to toss out the idea that how differentiated a
> patient is prior to the radiologic study may be an important variable.
> 3) In terms of asking overall what model of information exchange will
> provide the best diagnostic yield, I wanted to toss out the role of the
> clinicians looking not only at the impression of the radiologist but also
> the images themselves. This may be more relevant at a teaching hospital and
> more feasible in an emergency medicine setting where the time frame is
> condensed, but by looking at the area of interest that correlates with
> concerning physical exams findings, we have had good "catches."  It has
> forced the review of specific images that broadly "just don't look right"
> to  the emergency medicine physician.  This is typically done after the
> radiologist has viewed the images independently to avoid bias. For unclear
> or complicated cases, going over the clinical data as well as images
> together may be an important step.
> Thanks,
> David
> David Gordon, MD
> Assistant Clinical Professor
> Division of Emergency Medicine
> Duke University
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